The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 33 (page 170)

Case 33.13 G.T., 58 year old female. Radiology: 8.0 cm long nodular, constricting filling defect pyloric region. Base of duodenal bulb normal. Operation: large tumor mass with serosal extension and lymph node metastases. Billroth II. Gastric histology: mucinous adenocarcinoma extending through all layers of gastric wall. Duodenal histology: spread into first 2.0 cm of duodenal serosa, muscularis, submucosa and mucosa. No comment on Brunner's glands.

Case 33.14 A.A., 39 year old female. Radiology: ulcerated pyloric filling defect. Base of duodenal bulb normal. Operation: fungating pyloric mass with serosal extension and lymph node metastases. Duodenum appears normal. Billroth II. Gastric histology: poorly differentiated adenocarcinoma with signet ring cells. Duodenal histology: spread into duodenal mucosa for distance of 5.0 cm. Brunner's glands free of tumor cells.

As far as the histologic evaluation of duodenal spread of pyloric adenocarcinoma is concerned, it should be kept in mind that resections were not performed in cases with very extensive disease; in these cases specimens were not available for examination, and the extent of duodenal spread remains undetermined.

A striking feature in the 7 cases with microscopic evidence of duodenal spread is the fact that spread occurred for very short distances. In 3 cases it involved not more than the proximal 2.0 cm of the duodenum; in one it was found to extend to the commencement of Brunner's glands. In 2 cases the extent of spread was not mentioned, but judging by the descriptions it appeared to be very short; only in one case did spread extend into the duodenum for a distance of 5.0 cm.

Duodenal Spread in Relation to Gastric and Extragastric Extension

All 7 cases with microscopic evidence of duodenal spread had serosal involvement on the gastric side with extragastric extension to draining lymph nodes; one of the cases also had extension to the transverse mesocolon and spleen.
Most of the 16 cases without microscopic evidence of duodenal spread had widespread gastric and extragastric extension, e.g. to the serosa, omenta, draining lymph glands, liver and pancreas.


Role of Radiography

Radiography is highly sensitive and specific in the diagnosis of pyloric adenocarcinoma. In the present series of 50 cases the diagnosis was confirmed by endoscopy and/or operation in all. In only one case was a differential diagnosis considered; in this exceptional case the lesion had to be differentiated from malignant lymphoma (Chap. 34), cicatrization and obstruction due to benign pyloric ulceration (Chap. 29), acid corrosive stricture (Chap. 39) and eosinophilic infiltration. Malignant processes with rather different radiographic appearances are Carman ulcer, linitus plastica and early gastric carcinoma. Radiography also plays a useful role in the assessment of individual cases, as the state of the pyloric aperture and other features not readily visible endoscopically, may be determined.

Emptying of Solids and Liquids

It is surmized that destruction of the various anatomical constituents of the pyloric sphincteric cylinder, seen radiographically in all 50 cases, with associated lack of cyclical contraction and relaxation of the cylinder, will result in absent or severely impaired propulsion and trituration of solids (Chap. 18). Mucosal destruction and consequent lack of mucosal fold movements should aggravate these effects (Chap. 13).
Radiography shows that in the absence of actual obstruction, i.e. in the majority of cases, emptying of liquid barium is not usually delayed to an appreciable extent.

Duodenal Spread

Radiography is less accurate as far as evaluation of the duodenum in cases of pyloric adenocarcinoma is concerned. However, the smooth and regular appearance of the base of the duodenal bulb, seen in 40 of the 50 cases, is of importance. This "normal" appearance, seen in association with a constant filling defect involving the pyloric sphincteric cylinder, is corroborative evidence of pyloric carcinoma. The same holds true for smooth, concave indentations of the base of the bulb; this appearance, seen in 4 cases, is presumably due to external indentation by the pyloric tumor. In conditions such as malignant lymphoma, eosinophilic granuloma, corrosive stricture and tuberculosis, the duodenal bulb is usually deformed. Even in the presence of histologically proven duodenal spread, the duodenum may appear normal radiologically. In 20 cases of transpyloric extension, Koehler et al. (l977) noted duodenal abnormalities in 6, 14 appearing normal. In our 7 cases with microscopic spread duodenal abnormalities were seen in 2 only.

Macroscopically, at operation, duodenal spread may not be evident (Castleman l936; Paramanandhan l967). In 3 of our 7 cases the duodenum was considered to be normal at operation. In one duodenal spread was noted; in 3 the condition of the duodenum was not commented on.

The only unequivocal evidence of duodenal spread of pyloric adenocarcinoma is obtained by microscopic examination (Castleman l936). In the following cases microscopic duodenal spread of pyloric carcinoma was present in all:

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